YCI Sunil Hassan Using the coding techniques you have learned,

YCI Sunil Hassan Using the coding techniques you have learned, carefully read through the case study and determine the most accurate diagnosis code(s). Remember, check the chapter-specific, subchapter-specific, and category-specific notations within the Tabular List. Then, determine the most accurate procedure code(s) along with any modifier(s), if appropriate. WINTER HILLS HOSPITAL 565 VENTURA BYPASS • CENTRAL, FL 32811 • 407-555-4798 PATIENT: HASSAN, SUNIL ACCOUNT/EHR #: HASSSU001 Surgeon: Taylor Duggan, MD Asst. Surgeon: Carole Franks, PA and Wayne Hanson, RN Preop DX: Severe aortic valve incompetence with class II congestive heart failure and moderately severe left ventricular dysfunction Postop DX: Same Operative Procedure: Aortic valve replacement with St. Jude model #25A-101, serial #88073284; transesophageal echocardiography; temporary cardiopulmonary bypass with moderate hypothermia; sanguinous cardioplegia with topical hypothermia and warm blood cardioplegic reperfusion. Anesthesiologist: Randolph Sullivan, MD Anesthesia: General INDICATIONS: This 43-year-old male was found to have severe aortic valve incompetence with moderately severe left ventricular dysfunction and early onset of symptoms. Operation is undertaken for relief of symptoms, preservation of ventricular function, and prolongation of life. OPERATIVE FINDINGS: The left ventricle was enlarged grade 4/6, and hypertrophied grade 3/6, with reduced LV function diffusely. The ascending aorta was normal. The aortic valve was a tricuspid structure with myxomatous degeneration and prolapse, particularly of the noncoronary cusp. OPERATION: After induction of general endotracheal anesthesia and placement of appropriate monitoring devices, the patient’s chest and legs were sterilely prepped and draped. Primary median sternotomy was performed. The pericardium was opened and pericardial stays placed. Pursestrings were placed in the distal ascending aorta and right atrium. The patient was systemically heparinized and adequate anticoagulation was confirmed. He was cannulated and temporary cardiopulmonary bypass instituted at 2.4 l/min/m2 at 32 degrees throughout most of the 58-minute bypass time. The patient was core cooled and topically cooled until ventricular fibrillation ensured. The aortic crossclamp was placed. The left ventricular vent was placed through the right superior pulmonary vein. Right cardioplegia followed by subsequent direct ostial antegrade cardioplegia was administered and repeated at 20-minute intervals throughout the 39-minute cross-clamp time. An oblique aortotomy was performed. The valve was precisely excised after achieving effective cardiac arrest. The annulus comfortably accepted the 25-mm prosthesis. Interrupted nonpledgeted 2-0 Tycron sutures were placed circumferentially around the annulus, then passed through the sewing ring of the valve. The valve was seated and the sutures tied and cut. The valve seated nicely. The mechanism worked well. The root was irrigated and as we allowed the left heart to fill with blood, the aortotomy was closed with a double row of running 4-0 Prolene suture. With strong suction on the aortic needle vent and the patient in Trendelenburg position after a dose of warm blood cardioplegia followed by warm blood, the aortic cross-clamp was removed with a 34-minute ischemic time. The heart regained spontaneous rhythm but subsequently required DC cardioversion after some air entered the coronary arteries. The rhythm thereafter remained stable. We completed de-airing by TE guidance, rewarmed the patient. Temporary pacing wires were left on the surface of the right atrium and right ventricle. Two mediastinal tubes were placed at separate water-seal suction and to the autotransfusion device. He was weaned from cardiopulmonary bypass without difficulty. Protamine sulfate was administered, the patient decannulated. Hemostasis was achieved with electrocautery and the wounds closed in layers in the usual fashion. Sterile dressings were applied. The sponge, needle, lap, and instrument counts were noted as correct. The patient was transported directly to the CVRR in satisfactory condition. Taylor Duggan, MD

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